Thoracic

Question 1

1st and 2nd Line Treatment for patients with positive KRAS G12C mutations

Answer 1

First Line:
Platinum-based chemotherapy (± immunotherapy) is a recommended option for patients with KRAS mutations (eg, carboplatin plus paclitaxel).

Second/Subsequent Line:
Sotorasib
Adagrasib

Question 2

1st Line Treatment options for patients with metastatic EGFR mutant positive lung adenocarcinomas & associated exon mutations

Answer 2

EGFR mutations: Exon 19 deletion & Exon 21 L858R
Preferred first line treatment: Osimertinib
Other first line options: Erlotinib (± bevacizumab or ramucirumab), afatinib, dacomitinib, or gefitinib

Question 3

Third-generation ALK inhibitor that can overcome the largest number of acquired ALK resistance mutations

Answer 3

Lorlatinib
- Can overcome G1202R resistance mutation

Question 4

First Line Treatment for metastatic advanced Non-squamous lung cancer with no targetable mutations, PDL1 < 1%

Answer 4

Pembrolizumab/Carboplatin/Pemetrexed
Pembrolizumab/Cisplatin/Pemetrexed

Question 5

First Line Treatment for metastatic advanced Non-squamous lung cancer with no targetable mutations, PDL1 > 1%

Answer 5

Pembrolizumab mono therapy

Question 6

Preferred First Line Treatment for Metastatic NSCLC with ALK mutation (3)

Answer 6

Alectinib, Brigatinib or Lorlatinib should be given as frontline therapy given their improved efficacy including superior brain penetration.

Question 7

Preferred First Line Treatment for Metastatic NSCLC with ROS1 mutation (3)

Answer 7

Preferred: Entrectinib, Crizotinib, Repotrectinib

Question 8

Indications for permanent discontinuation of trametinib

Answer 8

–Symptomatic congestive heart failure
–Absolute decrease in LVEF of greater than 20% from baseline that is below LLN
– If no improvement in LVEF after holding for 4 weeks

Question 9

Adjuvant Osimertinib:
a. Indications
b. Dose & Duration
c. Most common AE

Answer 9

a. Indication: Resectable tumors stage IB – IIIA NSCLC with predominant non-squamous histology and EGFR exon 19 deletions or exon 21 L858R mutations

b. Treatment dose & duration: 80 mg daily for up to 3 years

c. Most common AEs: Lymphopenia, leukopenia, thrombocytopenia, diarrhea, anemia, rash, musculoskeletal pain, nail toxicity, neutropenia, dry skin, stomatitis, fatigue, and cough

Question 10

Adjuvant treatment indications for localized disease after definitive therapy if PDL1 >1%

Answer 10

Pembrolizumab and Atezolixumab are approved following resection and platinum-based chemotherapy in patients with stage II to IIIA non-small cell lung cancer (NSCLC) whose tumors have PD-L1 expression on ≥ 1%

Question 11

Preferred frontline option to offer patients who present with Metastatic/Advanced NSCLC [nonsquamous] that harbors an EGFR Exon 20 insertion mutation

Answer 11

Amivantamab + Carboplatin + Pemetrexed

Question 12

Preferred frontline treatment for patients with metastatic NSCLC with NTRK1/2/3 Gene Fusion (3)

Answer 12

• Larotrectinib
• Entrectinib
• Repotrectinib

Question 13

Preferred frontline and subsequent treatment for patients with metastatic NSCLC with MET Exon 14 Skipping Mutation (3)

Answer 13

• Capmatinib
• Crizotinib
• Tepotinib

Question 14

Preferred frontline treatment for patients with metastatic NSCLC with BRAF v600E mutation (4)

Answer 14

• Dabrafenib/Trametinib
• Encorafenib/Binimetinib
• Dabrafenib monotherapy
• Vemurafenib mono therapy

Question 15

Treatment option for patients with EGFR-mutated, advanced/metastatic NSCLC who develop progression on frontline Osimertinib

Answer 15

Amivantamab + Carboplatin + Pemetrexed as per the MARIPOSA-2 study

Question 16

Neoadjuvant systemic therapy options for eligible patients with resectable NSCLC and required criteria (2)

Answer 16

Neoadjuvant therapy: Nivolumab plus platinum-doublet chemotherapy
Criteria:
- Stage IB (only tumors = 4 cm) to IIIA OR
- Stage IIIB (only T3 ≤7 cm , N2 = ipsilateral mediastinal and/or subcarinal LN) NSCLC

Question 16

Which patients and what is recommended for adjuvant therapy for completely resected NSCLC and with PD-L1 of 1% or more who are negative for certain biomarkers?

Answer 16

Recommendation: Adjuvant Atezolizumab for patients with completely resected
- Stage IIB to IIIA
- Stage IIIB (only T3,N2)
- High-risk stage IIA NSCLC

Question 18

Consolidation immunotherapy option with unresectable stage III NSCLC and without disease progression after treatment with definitive concurrent platinum-based chemoradiation

Answer 18

Patients with stage III disease are recommended for consolidation with Durvalumab, irrespective of PDL1 status after with definitive concurrent platinum-based chemoradiation

Question 19

Adjuvant treatments approved for stage IIIA NSCLC

Answer 19

EGFR 19 or 21 deletion: Osimertinib x3 yrs
ALK positive: Alectinib x2 yrs
PDL1 > 1%: Atezolizumab x1 yr
Irrespective of PDL1 status: Pembrolizumab x 1 yr

Question 20

First Line Treatment of patients with stage IV squamous NSCLC with PD-L1 TPS > 50%

Answer 20

PD-L1 TPS > 50%:
Pembrolizumab
Atezolizumab OR
Cemiplimab monotherapy

Question 21

First Line Treatment of patients with stage IV squamous NSCLC with
A. PD-L1 Expression TPS, 1%- 49%
B. Unknown or PDL1 TPS <1%

Answer 21

A. PD-L1 Expression TPS, 1%- 49%:
- Pembrolziumab + Carboplatin + paclitaxel (or nab-paclitaxel) OR
- Cemiplimab + carboplatin + paclitaxel (or nab-paclitaxel)

B. Unknown or PDL1 TPS <1%:
Pembrolziumab + Carboplatin + paclitaxel (or nab-paclitaxel)

Question 22

Only statin approved for lorlatinib induced hyperlipidemia

Answer 22

Rosuvastatin

Question 23

Cardiac AE of each TKI + which of the following is the only one to cause high triglycerides and cholesterol?
Lorlatinib
Brigatinib
Alectinib
Crizotinib
Ceritinib

Answer 23

• Lorlatinib: AV Block + Hypercholesterolemia
• Brigatinib: Bradycardia
• Alectinib; Bradycardia
• Crizotinib: QTC Prolongation and Bradycardia
• Ceritinib: QTC Prolongation and Bradycardia

Question 24

First and Second Line treatment for metastatic NSCLC with KRASG12C mutation

Answer 24

First Line: SOC with platinum + immunotherapy or immunotherapy

Second Line/Subsequent therapy:
- Sotorasib
- Adagrasib

Question 25

Treatment of metastatic ROS1 NSCLC with brain mets (2)

Answer 25

Entrectinib or Repotrectinib